Psoriasis: More Than Skin Deep
By Perry, Patrick
For the seven million Americans living with psoriasis, new hope is emerging as research findings turn into medical advances. For decades, researchers have known that psoriasis-a chronic skin condition characterized by thick, red, scaly plaques that itch and bleed-can significantly affect overall quality of life. Now, dermatologists are finding a link between psoriasis and other serious medical conditions.
In the recent report published in the Journal of the American Academy of Dermatology, Alexa B. Kimball, M.D., M.P.H., and colleagues explored the link and presented recommendations on how dermatologists can help at-risk patients find appropriate preventive care or treatment.
“Our review found that people with more severe cases of psoriasis appear to have an increased incidence of psoriatic arthritis, cardiovascular disease, hypertension, diabetes, cancer, depression, obesity and even other immune-related conditions, such as Crohn’s disease,” Dr. Kimball said. “I advise patients at minimum to follow the nationally recognized recommendations that are appropriate for their age and gender. These include getting regular, comprehensive exams’ from their doctors and working to make lifestyle changes such as losing weight, exercising more, quitting smoking, reducing high blood pressure, controlling cholesterol, maintaining emotional health, and managing diabetes as needed.”
To bring you the latest news on psoriasis, the Post interviewed Dr. Kimball, associate professor of dermatology at Harvard Medical School in Boston.
Q: Could you tell Post readers about your recent report?
A: Our report attempted to do two things: first, synthesize current information about the development of comorbidities or other associated illnesses in patients with psoriasis. Recently, this has become a rapidly evolving field. Historically, we identified multiple issues relevant for psoriasis patients, such as increased risk of heart attack, obesity, and alcoholism. However, the problem was that most of the studies were done in hospitalized patients or dermatology clinics where you tended to a patient population with severe disease. In the most recent research, we’ve shown that even in the general population of psoriasis patients-from mild to severe- there are additional risks that the disease appears to confer.
Second and importantly, this particular work was designed to make sure that people were aware of age- and gender-based screening guidelines for the general population. Because psoriasis patients are at additional risk for some of these problems, we wanted to make sure that at minimum they were getting the appropriate recommendations based on the population as a whole.
Q: Are the findings widely disseminated among practitioners, and should patients discuss these risks with their doctors?
A: That is the important theme. A number of quite prominent papers have been published in the past two or three years in publications, such as JAMA, that have raised the awareness of some of these issues to the physician community. However, we don’t know what impact it has had on the average patient with psoriasis in terms of seeking medical care. It’s important not to be alarmist. In the report, we tried to say, “Listen, if you are a 50-year-old male, there are certain standard guidelines issued by ; the American Heart Association and the American Cancer Society that you should be aware of, and they apply to . you. Talk with your doctor about mak- ; ing sure your screening is up to date.”
Q: Is a patient with severe psoriasis at greater risk of heart attack?
A: The excess risk conferred by psoriasis appears to be greater the younger that you are, based on models published by Dr. Joel Gelfand. That’s why again it’s so important for that particular group to be aware of it. A 60-year-old male has a modestly high rate of a heart attack, so the additional increased risk among patients with psoriasis tends to become diluted. Gelfand also recently published work that demonstrated a four- to five-year decreased lifespan in severe psoriasis patients.
Q: Can people with psoriasis take steps to reduce their risk?
A: One important question that we do not have the answer to is, does treating the psoriasis adequately change your risk profile? In the moderate to severe category, this is a systemwide inflammation, so it’s possible that treating it with system-wide medication helps deal with some of the risks. We are all interested in answering that open question, but it takes quite a bit of time to answer. Obviously, if you have well-established risk factors for cardiovascular disease, such as obesity and a sedentary lifestyle, you can make changes immediately. While not easy to make, the changes can be done. At minimum, we’re trying to make that recommendation to patients.
Q: If people with the disease become depressed and overeat, they may become obese, which affects self-esteem and exacerbates psoriasis. Could this become a vicious cycle?
A: There’s clearly a potentially vicious cycle here. Obviously, excess weight may make psoriasis worse, and everything may spiral downward. However, the most recent data suggest that it’s not just the behavioral risk factors that confer additional risk. There’s something about the psoriasis alone as well. When we first identified some of these risk factors 20 or 30 years ago, people said, “It’s the psychosocial burden that leads to behaviors that Increase the risk, and maybe all risk is attributable to behavior.”
However, it appears that the inflammatory nature of psoriasis itself confers an additional Independent risk. Seventy to eighty percent of people with psoriasis have mild forms of psoriasis. Although we do observe slightly elevated risk In that population, it’s not huge. If you’ve got two spots on your elbows, it’s hard to imagine that as having a huge Impact on your entire system. In patients with thirty percent of their skin covered with disease, that’s a huge inflammation, so it’s very easy to make the leap to say that this Is going to have some total body effects. One of the interesting and important questions is, at what point does the switch flip from just being a localized, essentially minor issue to a much more dramatic one? We don’t know where that threshold is as yet.
Q: In your clinical experience, how does the disease affect your patients’ overall quality of life?
A: Quality of life is profoundly and dramatically affected by psoriasis. Even patients with mild to moderate disease may experience significant issues in their quality of life. Over the past decade, work has clearly shown that the quality of life impact for psoriasis is comparable to other chronic conditions-asthma, back pain, hypertension, even arthritis.
Q: Does psoriasis tend to make people reclusive?
A: The interesting thing about psoriasis is that it tends to typically not affect the face too much, and it doesn’t always affect the hands-although it can. Psoriasis patients become very good at hiding their disease in order to function in society. However, some become very reclusive. With long sleeves and long pants, many people hide their disease as best they can. Ironically, that’s sometimes to their disadvantage, because ambient sunlight does tend to help some people.
Q: Is there a wide range of treatments available for the disorder?
A: There are four main categories: biologies; traditional systemic therapies, such as methotrexate and cyclosporine; light therapy; and topical approaches. Each has its own benefit-risk profile and may affect different organ systems differently.
For the more severe patients, we now have lots of options, which is great. For the mild patients, we have a nice armamentarium. At the moment, the hardest group to treat is the moderate patients, because the risk-benefit ratio of some of the biologies may not be warranted, but they have too much disease to be easily managed with topicals, so it can be a problem.
Q: How strong is the genetic link In this disease?
A: While we are increasingly understanding genetics, it is complicated. So far, it appears unlikely we will find a single dominant gene that explains this disease. But there are clear links already to immunological function, which ties into why some of these other therapies seem to work quite well.
Q: What is the likelihood that a child with a parent who has the disease will develop it?
A: Children with one psoriatlc parent have a 10 to 25 percent chance of developing the disease; with two, they have about a 50 percent chance.
Q: What triggers affect the course of the disease, and does omcga- 3 or other supplements help?
A: Well-defined triggers include infection and stress, but how they affect individuals varies a bit. There are small data from small studies suggesting that primrose oil and fish oil might be beneficial for some people, but they do require some fairly high doses.
Q: If people are interested in participating in clinical trials, where should they go?
A: The Web site www.clinicaltrials. gov lists all the NIH- sponsored trials. Another option is to see if academic centers in your area are doing research. The National Psoriasis Foundation is also good for support groups and other information.
The great news for psoriasis patients is that we have a much better understanding of the impact of the disease and much better therapies over the past decade. Many psoriasis patients may have given up, because they were frustrated by the choices available and the toxicities of some of the medications. If you haven’t been in to see a physician or dermatologist for a while about your condition, now is a good time to go. -Patrick Perry, M.P.H. THE FIVE TYPES OF PSORIASIS INCLUDE:
* Plaque: Most common form of the disease
* Guttate: Appears as small red spots on the skin
* Inverse: Occurs in armpits, groin and skin folds
* Pustular: White blisters surrounded by red skin
* Erythrodermic: Intense redness over large areas.
-National Psoriasis Foundation
MODEL BEHAVIOR
“I’ve had psoriasis since I was five,” says CariDee English, winner of season seven on the popular TV show America’s Next Top Model. “My mother has it, so it was passed on to me. It wasn’t bad until I got to be about twelve or thirteen, then it covered 70 percent of my body until I was twenty-about two years ago. It was very tough. I tried every kind of medication, and nothing worked. While there is no cure for psoriasis as yet, I’m on a good biologic therapy that helped me tremendously and changed my life completely. I was ‘cleared.’ Two weeks after becoming clear, I was on Top Model.”
Juggling an international modeling career can, of course, be stressful-a recognized trigger for psoriasis.
“If the condition is going to come back, it’s going to come back,” says English. “I try to live day by day. Today’s a good day.”
To stay at the top of her game (and in control of her condition), English incorporates exercise, meditation, and yoga into her daily regimen.
“While I don’t always get it, sleep is really important,” adds the model.
As past spokesperson for the National Psoriasis Foundation, English traveled extensively, dispelling myths and raising awareness about the disease.
“Some people think that psoriasis is contagious, so many people are afraid when they see it, which is heartbreaking,” she told the Post. “I actually had to get out of a public pool because people thought I had a communicable disease. An old neighbor called social services on my mom: she thought my mother was beating me when the disease was all over my arms. People don’t know enough about psoriasis, so I encourage people to look it up, see what the disease looks like, and gain a better understanding of what people with psoriasis live through.”
As Carrie knows, the condition seriously compromises quality of life.
“I never went to pool parties,” recalls the twenty-two-year-old model. “I never wore shorts. Common activities can become very prohibitive, such as wearing a T-shirt when it’s ninety degrees or getting a haircut when the disease covers your scalp.”
Along her travels, English has learned much more about the disease.
“I’m lucky enough to be a global spokeswoman for the disease, and I learn something new every time I speak” says the busy CoverGirl Cosmetics model whose career is in high gear. “I always say, ‘I have psoriasis, but I don’t let psoriasis have me.’”
Copyright Benjamin Franklin Literary & Medical Society Jul/Aug 2008
(c) 2008 Saturday Evening Post, The. Provided by ProQuest Information and Learning. All rights Reserved.